D0008ENTRiSUPE

ED 055 869 SE 012 513

TITLE Family Planning Evaluation. Surveillance Report--Legal , , Annual Summary, 1970. INSTITUTION Public Health Service (DREW), Atlanta, Ga. Center for Disease Control. PUB DATE 70 NOTE 49p.

EDRS PRICE 11F-$0.65 HC-$3.29 DESCRIPTORS *Abortions; Family Planning; Graphs; Medical Services; *; *Reports; State Legislation; *State Surveys; *Statistical Data; Tables (Data)

ABSTRACT This report summarizes abortion informationreceived by the Center for Disease Control fromcollaborators in state health departments, hospitals, and other pertinent sources. Whileit is intended primarily for use by the above sources, it mayalso interest those responsible for family planning evaluationand hospital abortion planning. Information in narrative andstatistical form delineates the status of abortion reporting systems in the16 states that passed new abortion laws between January 1,1967 and December 318 19708 reported legal abortions, abortion ratios,demographic characteristics of the population of women who receivedlegal abortions, reasons for which legal abortions are performed,and procedures used to perform abortions. Four specialstudies on abortioa are highlighted: Joint Program for the Studyof Abortion; The Practice of Legal Abortion - City; Decreasein Septic Abortion Morbidity in a Municipal Hospital - LosAngeles, ; and Hospital Study of Abortion Services. A shorthistory of changes in the United States prior to 1970is presented, along with a more thorough review of legislative and judicialchanges affecting American abortion laws during 1970. Changesin the abortion laws and practices of Canada and Finland aredetailed under International Notes. 014 tt' iii e 0 A 2 4 J J

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I 1 PREFACE

This report summarizes information received from collaborators in state health departments, hospitals, and other pertinent sources. It is intended primarily for their use, but may be of interest to others with responsibility for family planning evaluation and hospital abortion planning.

Contributions to this report are most welcome. Please Address:

Center for Disease Control Attn: Chief, Family Planning Evaluation Activity Epidemiology Program Atlanta, Georgia 30333

Center for Disease Control David J. Sencer, M.D., Director Epidemiology Program Philip S. Brachman, M.D., Director

Family Planning Evaluation Activity. . Carl W. Tyler, Jr., M.D., Chief Judith P. Bourne, R.N., M.S. James B. Kahn, M.D. S. Beach Conger, M.D. Jack C. Smith, M.S., Statistician

U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE PUBLIC HEALTH SDRVICE1 HEALTH SERVICES AND MOTAL HFALTH ADMINISTRATION CENTER FOR DISEASE CONTROL EPIDEMIOLOGY PROGRAM, FAMILY PLANNING EVALUATION ACTIVITY ATLANTA, GEORGIA 30333 I. SUMMARY

In 1970, more than 180,000 legal abortions were performed in the United States and reported to the Center for Disease Control from 19 states and the District of Columbia. Abortion practices in the United States vary widely, in part because of variations in state abortion laws. Twenty-eight states restrict legal abortions to situations where it is necessary to preserve the pregnant woman's life, while four states allow abortion on the decision of a pregnant woman and her . Eighteen other states and the District of Columbia allow abortions under a variety of legally specified or restricted conditions.

New York is the only state among those with the least restrictive abortion laws which permits abortions for non-resident women. Between July 1, the date the New York law went into effect, and the end of the year, New York reported the nation's highest abortion to live-birth ratio, 534 abortions per 1,000 live births.More than 36,000 non-resident women received abortions in New York during those 6 months.

Although the largest number of abortions, reported by age, were obtained by women age 15-24, pregnant women who were either less than 15 or older than 40 had the highest ratios ofabortions per 1,000 live births. Two-thirds of the abortions reported by marital status were performed on unmarried women. Nearly half of the abortions reported by parity were performed on women who had no living children. Four of six states which reported legal abortions by race had higher abortion ratios for white than for black women. Two-thirds of the abortions were performed by the end of the 12th week of ; 97.5 percent were performed by the end of the 20th week. In seven states which reported type of operative procedure used, 76 percent of the abortions were performed by either suction or sharp curettage.

Reports of several special studies on abortion are included. One of the most important of these is a preliminary report based on data collected by the Joint Program for the Study of Abortion on early complications of legally performed abortions. Results showed a one percent incidence of major complications. Three of the studies dealt with abortion practices in . Between July 1 and December 31, 1970, a total of 68,995 legal abortions were reported to the New York City Health Department. Analysis of those abortions by type of facility they were performed in showed that women cared for in publicly financed facilities tended to have abortions later in pregnancy and more often by a non-DO method than women who were served as private patients. In New York City fewer deaths from illegal abortion were reported after the new law went into effect thanin the previous 6 months. Eight deaths associated with legal abortion were reported between July 1 and December 31. Estimated legal abortion mortality rates in New York City were higher for black and Puerto Rican women than for white women. The estimated mortality rate for abortions performed after the 12th week of pregnancy was three times as great as the rate for abortions performed earlier in gestation. The overall death

1 rate for legal abortion in New York City was 11.6 per 100,000 abortions during the first 6 months. Investigation of the death of one out-of-state woman after a New York City abortion led to the discovery of six uterine perforations resulting from aspiration abortions performed by one physician. Gestation of greater than 12 weeks at time of abortion was found to be the factor most closely associated with incidence of this complication.

During the time period 1966-1970 admissions for treatment of septic, non-hospital induced abortions at one California hospital decreased by more than 50 percent while the number of legal induced abortions at that hospital rose from two to more than 3,000 per year.

A short law changes in the United States prior to 1970 is presented, along with a more thorough review of legislative and judicial changes affecting American abortion laws during 1970. Changes in the abortion laws and practices of Canada and Finland are detailed under International Notes.

2 II. INTRODUCTICN

In 1969, four of the nine states with recently changed abortion laws reported 12,417 legal abortions to the Center for Disease Control (CDC). By contrast, in 1970 more than 180,000 abortions were reported from 19 states and the District of Columbia. In the year intervening these two reports, the United States has had unprecedented change in laws and practices related to legal abortion.

III. STATUS OF REPORTING

As of December 31, 1970, statewide abortion reporting systems were in effect in 14 states. Table 1 summarizes the status of abortion reporting in the 16 states that passed new abortion laws between January 1, 1967, and December 31, 1970. This table identifies the source of abortion data for each state and the frequency with which each state compiles statistics on legal abortion. Arkansas and New Mexico were the only two of the 16 states without a statewide abortion reporting system in effect in 1970. Many of the new abortion laws enacted since 1967 require records to be filed with the state health department within a specified time after an abortion is performed; these records are the primary source of abortion data in those states. Five other states currently take their abortion data from fetal death certificates. Unfortunately, fetal death certificates do not always provide all the data appropriate for induced abortion. Moreover, fetal death certificates are not available as a source of abortion data in states where reporting of fetal deaths-is not required, unless it occurs after the 16th week of gestation.

Several other states are now in the process of developing an abortion reperting system, although in rany areas of the country individual hospitals remain the only source of accurate information on legal abortion.

3 Table 1

ABORTION REPORTING STATES WITH ABORTION LAWS ENACTED SINCE JANUARY 1, 1967 DECEMBER 31, 1970 Source of Data

en "O c 'E c C > 0 cs).1:17,-, E :E.r, 0 ..-:. . c to.,.., ,c ...... State c 0 c . ;,-.a. -E G., 7.4 4, :a -0.1; >.IA 473 ',.. 2 k 8': coE cr E CI :5 2 o.Ct I I et li, 't CO 0 CD CP f. 0 5,.. u: 8 "a c 41 cac'Ins0 6' u. u 0 zcn Alaska Eli-Monthly V Arkansas V California Quarterly VI Monthly V Delaware Annually V Georgia Monthly V Hawaii Monthly V V2 Kansas Annually V Maryland Quarterly V New Mexico V New York City3 Weekly V V V Upstate New York Monthly V North Carolina Annually V4

Oregon MontZily V South Carolina Monthly V Virginia Monthly

Washington Monthly V

1. Beginning April 1, 1971, hospitals in California will report only numbers of abortions performed and numbers of deaths associated with legal abortions. 2. In addition to reporting of abortions on fetal death certificates sent to the state health department, hospitals in Hawaii volun- tarily send case reports to the University of Hawaii Schcol of Public Health, which was requested by the state legislature to study abortion practices in the state. 3. aborted before the 16th week of gestation are reported to the health department on a "Certif icate of Termination of Pregnancy;" those aborted during or after the 16th week are reported on an abridgedTrZSdeath certificate. New York CitY hospitals also submit a weekly report of abortions performed, by method used and length of gestation. 4. Hospitals are asked but not required to submit case reports on abortions tl the Committee on Mammal Health of the Medical Society of the State of. North Carolina for compilation and analysis.

4 IV. REPORTS FROM STATES

Table 2 shows reported legal abortions for 14 states and the District of Columbia. A total of 175,508 abortions were reported from these jurisdictions, giving an overall ratio of 178 abortions per 1,000 live births. The range between legal abortion ratios for these states is very great, from a low of 7 in Georgia to 534 for the State of New York.

Table 3 shows legal abortion ratios from 13 hospitals located in Alabama, Kansas, Massachusetts, Pennsylvania and Wisconsin. All of these states allow legal abortion in a variety of circumstances not restricted to situations in which the life of the pregnant woman is threatened; none had statewide abortion reporting systems in effect for the entire year of 1970. The 13 hospitals reported a total of 4,611 abortions performed during 1970, which, in addition to the 175,508 reported abortions shown in Table 2, makes a total of 180,119 abortions reported for the country in 1970.

Only four states--Colorado, Delaware, Georgia and Oregon--had abortion data broken down by month for the complete year of 1970 (Figure 1). Although these states demonstrate widely divergent abortion practices, in each state the abortion ratio increased over the course of the year. Although Georgia's ratios throughout the year were lower than those of the other states, the legal abortion ratio for Georgia increased more than five-fold between January and Decerber.Abortion ratios in Colorado and Delaware more than tripled over the course of the year, and the ratio for Oregon increased by 71 percent.

5 Dune 4

REPORTED LEGAL ABORT/ONRATIOS SELECTEDSTATES 1970

Months Current Law Reported Abortions/ 2 2 State In Effect Waal Abortions Live Births Live Bire

Alaska 5 5 408 3,390 120 California 12 12 62,672 364,007 172 Colorado 12 12 2,263 42,758 53 Delaware 12 12 560 10,234 55 Dist. of Columbia 19 8 4,5793 17,067 268 Georgia 12 12 705 96,069 7 Hawaii 9-1/2 9-1/2 2,741" 204 Maryland 12 6 3,210 3.13.,;Sill 101 New Mexico5 12 6 797 10,937 73 New York 6 6 87,530 163,847 534 (Upstate) 6 6 (18,535) (86,632) (City ) 6 6 (68,995) (77,215) (281944j North Carolina 12 12 1,293 13 Oregon 12 12 7,196 199 South Carolina 11 11 392 F6,3i: 8 Virginia 6 7 635 46,005 14 Washington 1 1 527 6,345 83

TOTAL 175,508 987,090 178

* All states with data available.

1. In some instances, data were not available for all monthsthe current law was in effect. 2. Reported legal abortions and live births by place of occurrence.Live birth data taken from Monthly Vital Statistics ReportProvisional Statistics, Vol. 19, No. 12, March 4, 1971, published by theNational Center for Health Statistics, HSMHA, DHEW. 3. Abortions reported by all but twc hospitals. 4. "Elective abortions" only. 5. Data obtained from all New Mexico hospitals for varying 6-monthperiods in 197C

6 Table 3 LEGAL-ABORTION RATIOSSELECTED HOSPITALSRetorting 1970 Live Abortions/1,000 U.Hospital of Kans.Ala. Med.Med. Ctr.Ctr. 1 KansasBirmingham,Location City, Ala. Kans. JulyJan. - Dec.Period Abortions 1,200 393 Births 3,196 900 Live Births 1,333 123 PeterNewton-WellesleyBeth Israel Bent Brigham , Mass. Jan. - Dec. 194561103 1,2173,169 NONE 177 =1.85 AlbertUniversityPhiladelphiaPennsylvaniaGeisinger Einstein Med. Hosp.Gen. Ctr. ,Danville,Boston, Mass. Penn, Penn. JulyJan.JulyJan. - -Dec. Dec. 1,118 211440148 43 2,9101,701 NONE 550823 256259384 78 MountMadisonTOTALUniversity Sinai Gen, Madison,Milwaukee,Madison, Wisc. Wisc.Wisc. JulyJan. - Sept.JuneOct. 19 4,611 128 65 7 17,6741,5841,094' 530 261123117 4 17.--Aortions2. and live birth figures are estimated.Live birth figure was estimated from reported abortions and abortion ratio.

Figure I LEGAL ABORTION RATIOS, COLORADO, DELAWARE,GEORGIA, AND OREGON, 1970

300

280

OREGON 260. DELAiNARE COLORADO 240 WINO II GEORGIA 220

200

180

160

140

120

100

80 /

60...... 40

20 01=1...... M'OMMO WOW. JAN. FEB. MAR. APR. MAY JUN. JUL. AUG. SEP. OCT. NOV. DEC. 1970 10 Although the ratios in Table 2 compare abortions and live births which occurred in the same state within a given period of time, they do not necessarily indicate the ratio of abortions to live births for women living in those states. Mote than 36,000 women from other states had abortions in New York in the last 6-months of 1970. Since the New York State abortion law went into effect on July 1, 1970, New York has become the major source of legal abortion services.not only for its own residents but also for women from many states ehst of the Mississippi River. Therefore,- to estimate the legal abortion ratio.for women who live in any state, it is necessary to know not only how many abortions were performed in that state, but also how many of those abortions were performed on out-of-state women and how many women from that state obtained aborticns somewhere else. Figures 2 and 3 show reported legal abortion ratios for women in each state and the District of Columbia for the last 6 months of 1970. The white bars represent abortions (per 1,000 live births in state) performed in state on residents of the state; the black bars represent abortions (per 1,000 live births in state) performed out-of-state on residents of the state. Of the 16 states with new abortion laws (listed in Table 1), only 6; viz, California, Colorado, Kansas, Maryland, New Mexico and New York, allow abortions for out-of-state women, and residency data were available for only four of these states. The proportion of abortions 1 performed on non-residents wasreported to be 7 percent in California, 8 percent in Colorado, 3 percent in Maryland, 25 percent in Upstate New York, and 51 percent in New York City. The abortion ratios for these states have been adjusted to allow for abortions performed on women from out-of-state (Figures 2 and 3). The assumption has been made that all 5 abortions reported for other states were performed on residents. State of residence is known for out-of-state women who received abortions in Colorado and New York. Abortions performed on non-residents in these two states are the basis for the out-of-state abortion ratios represented in Figure 1 and 2.

In Figure 2 the states are organized by geographical regions. While there is wide disparity between abortion ratios of the 50 states, somewhat greater similarity exists between states within geographical regions. The Middle Atlantic Region has the highest overall ratio (174) with almost all abortions obtained by women from each state in that region having been performed in New York. The in-state abortion ratio for 'Pennsylvania is based on abortion data from only four hospitals and live birth data from the whole state.More complete reporting from Pennsylvania would certainly increase the in-state portion of the abortion ratio for that state.

The Pacific Region has the second highest ratio (164) and is the only area where all reported abortions were performed in each woman's home state. Figure 2 RATIOS OF REPORTED LEGAL ABORTIONS TO LIVE BIRTHS, BY STATE OF RESIDENCE, IN GEOGRAPHIC ORDER, JULY-DECEMBER 1970

ABORTIONS PER 1,000 LIVE BIRTHS

50 100 150 200 250 300 350

NEW ENGLAND (89) Maine New Hampshire

. Vermont Massachusetts Rhode Island MIDDLE ATLANTIC (174) New York New Jersey Pennsylvania EAST NORTH CENTRAL (34) Ohio Indiana Illinois Michigan Wisconsin WEST NORTH CENTRAL (26) Minnesota Iowa Missouri North Dakota South Dakota Nebraska Kansas SOUTH ATLANTIC (47) Delaware Maryland_ Dist: Columbia Non-msidents not identified Virginia West Virginia North Carolina South Carolina Georgia Florida LAST SOUTH CENTRAL (9) Kentucky Tennessee Alabama Mississippi WEST SOUTH CENTRAL (4) Arkansas ri Abortion in state Louisiana of Residence Oklahoma Texas III Abortion performed MOUNTAIN (29) in another state Montana Idaho Wyoming Colorado

New Mexico 1 Arizona Utah Nevada PACIFIC (164) * Washington Oregon California ** Alaska Hawaii DECE21BER13 - DECEMBER 31, 1970. ** JULY 29 - DECEMBER 31, 1970

() RATIO FOR REGION The third highest ratio is found among the four northern-most jurisdictions listed under the South Atlantic Region - -Delaware, Maryland, the District of Columbia and Virginia. None of these jurisdictions restrict abortions to situations where it is necessary to preserve a woman's life, and all four show both abortions performed in-state and abortions performed out-of-state. The next highest regional ratio is that of New England, where, except for Massachusetts,.virtually all reported abortions were performed in New York.

Ratios for the remaining regions decrease in relation to their distance from New York and as they become less urban.This is consistent with Pott's conclusion, based on data from many countries, that the Tatio of induced abortions per live birth is always'higher in urban areas.' Kansas in the West North Central Region and Colorado and New Mexico in the Mountain Region, the only states in those areas with updated abortion laws, are exceptions to this trend.

Figure 3 shows the same in-state and total abortion ratios by state of residence listed in rank order. The District of Columbia is first with an abortion ratio of 296; 95 percent of the abortions were performed in the District. Three factors have operated to inflate the ratio for the District of Columbia. First, although the residencey of women who received abortions in Washington, D.C., was not reported, the D.C. ratio would be smaller if abortions performed on non-District women had been subtracted from the total, as was done for New York. Secondly, the District ratio was higher than that for New York State because it is a city rather than a state. Most abortions are performed in cities; as a result, large cities usually have a much higher abortion ratio than the state of which they are a part. For instance, the ratio for New York City, excluding non-New York State residents, is 434, compared with 160 for Upstate New York and 289 for the state as a whole. In Washington, D.C., there is no large rural and suburban area with live births to dilute the metropolitan area's abortion ratio.Finally, Washington, D.C., was the first jurisdiction to have its abortion law invalidated by judicial decision (See Legal Notes Section).

With the exceptions of the District of Columbia and Massachusetts, each of the first 11 states in Figure 3 have passed new abortion laws since 1967. The 5 states with the least restrictive laws (Alaska, Hawaii, New York, Washington and Oregon) listed in categories six and seven in Table 22 (Legal Notes) are all ranked in the top 10. However, those with laws similar to the American Law Institute (ALI) Model Penal Code on Abortion are distributed in this rank order between 5 and 47.Women residing in 10 of the states which permit abortions only to preserve a woman's life had higher abortion ratios than women from Georgia, South Carolina and North Carolina, which have laws similar to that recommended by the ALI. Although Georgia is the only state with an ALI abortion law which has been further liberalized by court decision, more abortions were performed on Georgia women in New York than in Georgia. Considering both figures 2 and 3, it appears that at least three factors affect the overal abortion ratio in individual states: (1) the status of abortion law in the state, (2) regional characteristics, and (3) the state's proximity to New York. Figure 3 RATIOS OF REPORTED LEGAL ABORTIONS TO LIVE BIRTHS, BY STATE OF RESIDENCE, IN RANK ORDER, JULY DECEMBER 1970

ABORTIONS PER 1,000 LIVE BIRTHS

50 100 150 200 250 300 350

1 Dist. ColuMbia Non-residents not identified 2 New York 3 Oregon 4 Hawaii 5 California 6 Massachusetts 7 **Alaska 8 Maryland 9 Kansas 10 *Washington 11 New Mexico 12 New Jersey 13 Delaware 14 Connecticut 15 Colorado 16 Vermont 17 New Hampshire 18 Rhode Island 19 Midhigan 20 Maine 21 Pennsylvania 22 Virginia 23 'Ohio 24 Illinois 25 Wisconsin 26 Florida 27 Georgia 28 North Carolina 29 Minnesota 30 Nebraska 31 Indiana 32 South Carolina ft Abortion in state 33 Iawa 1-.-1 of residence 34 Wyoming 35 West Virginia is Abortion performed 36 Kentucky MO in another state 37 Alabama 38 Missouri 39 Tennessee 40 North Dakota 41 South Dakota 42 Oklahoma 43 Louisiana 44 Mississippi 45 Nevada 46 Texas 47 Arkansas 48 Montana 49 Arizona 50 Idaho 51 Utah

** JULY 21 - DECEMBER 31, 1970

* DECEMBER 3 - DECEMBER 31, 1970 Tables 4 through 9 describe demographic characteristics of the population of women who received legal abortions in a number of states in 1970. Table 4 presents age distribution of women who had legal abortions in the nine states which reported age. The largest number of abortions (36 percent) were obtained by women ages 20-24, the next largest group included women ages 15-19. Twenty-two percent of the women were 30 or older, and less than 1 percent were younger than 15. Age distribution data from selected hospitals tend to correspond with these general trends, except in the case of Philadelphia General Hospital, where 11 percent of the abortions performed between July 1 and December 31, 1970 were obtained by girls less than 15 years old. Philadelphia General Hospital has had to restrict the number of abortions performed there every month due to limited space and personnel, and has assigned adolescents a high priority among the many women seeking abortions at that facility.

Figure 4 compares percent distributions of legal abortions by age in those states with data available for 1969 and those states with data available for 1970. The 1970 data show a smaller proportion of abortions obtained by women less than 20 years old and a larger proportion obtained by women in each 5-year age group between 20 and 34, compared with 1969.

Although women at the age extremes had fewer abortions in relationship to the total number of abortions performed, they have the highest age- specific abortion ratios (Table 5). In Oregon girls less than 15 years old had nearly three abortions for every ltve birth; girls less than 15 also had more abortions than live births in Alaska and Colorado. New York City is the only reporting area which shows a higher abortion ratio for women age 15 through 19 than for those 14 years old or less. New York allows women 17 years old or older to consent to their own abortions, and may attract a disproportionate number of abortion patients age 17 to 20. A young woman age 17 to 20 may sign for her own abortion in New York, although she might be unable to do so in her own or another state. Table 4 LEGAL ABORTIONS BY AGE SELECTED STATES 1970* State < 15 15-19 20-24 % No.' 25-29 % No. 30-34 % No. 35-39 % > 40 % UnknownNo. % No. Total Colon*Alaska 61 5 2.71.2 695 97 30.723.8 697115 30.828.2 364102 16.125.0 214 53 13.0 9.5 226 26 2 70.0 6.4 10 - 2.5 - 06 0.30.0 2,263 408 100.0 Hawaii3GeorgiaDeldareNew York City 125 1932 0.70.34.53.4 9,513 526173155 21.619.224.527.7 16,263 1,079 159155 37.039.422.627.7 8,278 537152 82 18.819.621.614.6 5,026 281 8974 12.613.211.410.3 3,223 190 6850 9.66%97.36.9 1,260 101 3225 2.93.74.5 271 80 0.60.30.0 43,959 2,741 560705 100.0100.0 p OregonUp-StateSouth Carolina' New York 138100 6 0.71.51.4 2,3964,490 110 28.183.324.2 2,5626,262 112 35.633.628.6 3,218 977 62 13.617.415.8 2,102 611 47 12.011.3 8.5 1,554 374 26 6.65.28.4 661176 29 3.67.42.4 110 00 0.60.0 18,535 7,196 392 100.0100.0 TOTAL 4 29 - December 31. 505 0.7 Provisional18,155 data. 23.7 27,404 35.7 13,772 17.0 8,497 11.1 5,737 7.5 2,294 3.0 395 0.5 76.759 100.0 fel 1?titily4.3.2. RppresentsMarchAbortionsof certificates 11 - performedDecemberonly abortions results 31,on women1970. inreported incomplete35 or older.by certificates data on age. filed with the New York City Health Department. Elective abortions only. Relative magnitude of totals is not affected. July - December. Delayed filing *All'states6..5, February with- December. data available. New York State exclusive of New York City, July - December. Table 5 1 AGE-SPECIFIC LEGAL ABORTION RATIOS SELECTED STATES* 1970

State < 15 15-19 20-24 25-29 30-34 35-39 > 40 Overall

Alaska 1,667 191 91 120 125 101 114 120 2 Colorado 1,419 100 42 32 43 76 - 53 Delaware 463 75 42 33 61 83 144 55 Georgia 67 8 4 7 9 14 20 7 Hawaii 731 304 217 133 159 261 543 204 New York City 812 1,053 610 375 431 535 777 569 Up-State New York 798 408 193 140 180 246 318 214 Oregon 2,778 370 169 114 167 207 374 199 South Carolina 26 10 6 6 10 11 37 8

Overall 425 256 178 134 169 221 326 186

1. Calculated as the number of legal abortions in women of a given age group per 1,000 live births to women of the same age group. Sources ofdata are Table 2 of this report for abortions by age and Table 1 for total1970 live births. Age distribution of live births based on 1967 VitalStatistics of the United States, 1969 Georgia Vital and Morbidity Statistics,and 1969 Maryland Annual Vital Statistics Report. 2. Colorado reports oldest age group as 235. The relative magnitudeof the overall ratios would not be dhanged by further age breakdown.

*All states with data available.

Although the percent distribution of legal abortion by age for 1969 and 1970 (Figure 4) indicates that in 1970 a smaller proportion of the total number of abortions were obtained by women younger than 20, as compared with 1969, legal abortion ratios (Figure 5) show not only that the abortion to live birth ratio has increased for every age group, but also that the increase has been greatest for women in the 15-19 age group. Relatively few pregnancies occur to women less than 20 years of age or older than 35. Therefore, increased utilization of legal abortion among women in these age groups has less effect on the overall percent distribution by age than a similar or even less dramatic increase in utilization of legal abortion by women between the ages of 20 and 35. Figure 4 PERCENT DISTRIBUTION OF LEGAL ABORTIONS BY AGE, SELECTED STATES, 1969-1970

60- 1969 50- 1970 40-

20-

10-

0 <15 15 - 19 20 -24 25 -29 30-34 35+ AGE GROUP 1969 PERCENT DISTRIBUTION IS BASED ON DATA FROM CALIFORNIA, COLORADO,AND GEORGIA. 1970 PERCENT DISTRIBUTION IS BASED ON DATA FROM ALASKA, COLORADO, DELAWARE, GEORGIA, HAWAI I, NEW YORK, OREGON, AND SOUTH CAROLINA Figure 5 AGE,. SPECIFIC LEGAL ABORTION RATIOS, SELECTED STATES, 1969-1970

m1969 400 1970 350

300

250

200

150

100

50

0 <15 15-19 20-24 25-29 30-34 35+ AGE GROUP SEE FIGURE 4 Data from seven states shows that two-thirds of the women were not married at the time of abortion (Table 6). The cateitory of "unmarried" includes women separated, widowed, divorced or never married. This represents a decrease in the percent unmarried When compared withthe 1969 data. The 1969 Annual Summary, wbiCh contained marital status on Abortions from only three states, showed a total of 73.2 percent unmarried at the tine of abortion. TAble 7 shows estimated legal Abortion ratios by marital status for six states. Although married women had one-third of the abortions in the states shown in Table 6, the Abortion ratio for married women in those states is only one-eighteenth the ratio forunmarried women. In Oregon, unmarried women had almost twice as many Abortions as live births.

Table 6

LEGAL ABORTIONS BY MARITAL STATUS SELECItD STATES* 1970

Married Unmarried1 Unknown Total State No. % No. % No. % No. %

2 Alaska 157 38.5 249 61.0 2 0.5 408 100.0 Delaware 169 30.2 391 69.8 00.0 560100.0 Georgia 308 43.7 397 56.3 00.0 705 100.0 Maryland 1,015 31.6 2,182 68.0 13 0.4 3,210100.0 Up-State N.Y.4 6,89437.2 11,641 62.8 00.0 18,535100.0 Oregon 1,655 23.0 5,541 77.0 00.0 7,196 100.0 5 South Carolina 14637.2 246 62.8 00.0 392 100.0

TOTAL 10,34433.4 20,647 66.6 15 0.031,006 100.0

1. Unmarried includes women who are separated,widowed, divorced, and women Who have never married. 2. Provisional figures, July 29 - Decelber 31. 3. July - Dedember. 4. New York State, exclusive of New York City,JuIy-December. 5. February - DeceMber.

*All states with data available.

17 Table 7

ESTIMATED LEGAL ABORTION RATIOS BY MARITALSTATUS1 SELECTED STATES* 1970

State Married Unmarried2

Alaska 51 830 Delaware 19 272 Georgia 4 37 Maryland 37 480 . Oregon 50 1,990 South Carolina 4 35

Overall 18 334

1. Calculated as legal abortions to women of a given marital status per 1,000 live births to women in that marital status.Live births to married women are legitimate births; live births to unmarried women are assumed to be registered as illegitimate births. *distribution of live births-based.ona967.1rital'Statistics of:the:U.S., '1969,1GeorKia Vital:and:MOrbidity Staastics, and 1969 Maryland Anntal laza/'Statisties'Repoirt. 2. Unmarried includes women Who are separated, widowed, divorced, and women who have never married.

*All states with data available.

Table 8 presents race-specific legal abortion ratios for six states, broken down into White, black and "other"races. The Abortion ratio for white women is higher than for black women in every state except Alaska and Maryland. In South Carolina the Abortion ratio for white women is four times as hih as that for blaCk women in the same state.

20 Table 8

LEGAL ABORTIONRATIOS1 BY RACE SELECTED, STATES* 1970

State White Ratio Black Ratio "Other" Races Ratio White/Black Ratio 2 Alaska 141 185 65 0.8 4 Delaware 56 483 1.2

Georgia 9 4 5. 2.2 Hawaii5 322 110 154 2.9 Maryland6 86 154 88 0.6 South Carolina7 12 3 14 4.0

1. Ratios calculated as the number of race-specific Abortions per 1,000 race-specific live births.Racial distributions of live births basedOp 1967 Vital Statistics of the U.S. 2. July 29 - December 31. 3. Includes Bladk and "Other" (live births and Abortions). 4. White abortions per 1,000 live births/Bladk and "Other" abortions per 1,000 live births. 5. Mardi! 11 - December 31. 6. July - December. 7. February - December.

*All states with data available.

Table 9 shows legal Abortions by nmmber of livingChildren for women in Alaska, Georgia, and South Carolina.Nearly onehalf of the women (49.2 percent) who had Abortions in thesestates had no living Children. Slightly more of the women had two living Children than had eitherone, three, four or more.

Table 9

LEGAL ABORTIONS BY NUMBER OF LIVING CHILDREN SELECTED STATES* 1970

Number of Living Children 0 1 2 3 4 > 5 Unknown Total State No. % No. % No. % N . % No. % No. % No. % No. % 1 Alaska 225 55.1 47 11.547 11.5 35 8.6 27 6.620 4.9 7 1.7 408 100. Georgia 300 42.699 14.0 113 16.0 111 15.7 49 7.0 33 2 4.7 0 0.0 705 100. South Carolina 216 55.1 42 10.750 12.L 33 8.4 26 6.6 22 5.6 3 0.8 392 100.'

TOTAL 741 49.2 188 12.5 210 14.0 179 11.9 102 6.8 75 5.010 0.7 1505 100.

1. July 29 - December 31, provisional data. 2. February - December.

*All states with data available.

Table 10 presents data fromthe 10 states showing the stated reason for which legal abortions were performed. The first four categories, , physical health, risk of fetal deformity, and or incest, correspond to the legal indications for abortion in states with laws modeled after the ALI Model Penal Code on Abortion.As in 1969, the most common reason stated for legal abortions was danger to the mentalhealth of the pregnant woman. However, the proportion.of abortions nerfc.rmed for this reason has decreased to 76.6 percent, down from 90.6 percent in 969. The 1970 data show 17.3 percent under "other" reasons or with tha reason unstated or unknown, compared with only 0.4 percent listed under "other" reasons and none listed as "unknown" during 1969. These differences reflect changes in the status of abortion law in several of these states. New abortion laws enacted in Alaska and Hawaii in 1970 provide no restriction on the reasons for which women may obtain legalabortion. In Alaska 89.7 percent of the abortions were performed for reasons other than those four specifically listed in Table 10. The stated reason for most abortions listed in the "other" category for Alaska was "unwanted pregnancy." In Hawaii, 99.3 percent of the abortions were performed without a stated reason. Whereas in 1969 Georgia listed no abortions under "other" or "Imaknown", more than 10 percent of Georgia's 1970 abortions were listed in these categories. This reflects a 1970 Federal District Court decision in Georgia which forbade the state to limit the reasons for which abortions can be performed (See Lega.:".Notes).

20 Table 10 INDICATIONS FOR ABORTION SELECTED STATES* 1970 tOtateTV Mental HealthNo. % Physical HealthNo. % Risk of FetalNo. Deformity % Rape or IncestNo. % No. Other % No. Unknown - % No. Total % AlaskS1Colorado 2,020 533 22 95.289.3 5.4 125 14 9 2.55.52.2 1019 5 0.81,21.8 74 16 0.23.31.5 366 20 89.7 0.40.0 25 00 0.00,0,/./ 2,263 .560408 100.0 DelawareHawaii2Georgia 520 8 73.8 0,3 6272 7 0.32.28.8 1136 3 0,40,15,1 12 0 0.40.01.7 2674 1 10.5 0.80.0 2,761 21 99.3 0.10.1 2,7803,210 705 100.0100.0 MarylandOregonNorth Carolina 6,9821,1383,085 336 88.096.197.0 333136 39 10.5 9.94.6 149710 0.83.61.3 56 29 0.50.80.7 08 0.00.1 01 0.30.00.0 7,47641,293 392 100.0100.0 Virginia°TOTALSouth Carolina 15.,103 459 85.?76.672.3 813 16 2.54.1 223 16 1.12.5 173 1 0.90.2 477 0 2.40.0 2,933 143 22.514.9 19,722 635 100.0100.0 2.1. MarchJuly 29 11 - -December December 31. 31, provisional data. Includes 2,739 elective and 41 therapeutic abortions 4.3. JulyindicationTotalas reported- December.number may byof be theindications stated University for mayeach of not abortion. equal total abortions performed as more Hawaii School of Public Health. than one 6.5.*All states with data available. JanuaryFebruary - -July. December. Table 11 LEGAL ABORTIONS BY WEEKS OF GESTATION SELECTED STATES* 1970 <9 9-12Weeks of Gestation at Time of Abortion 13-16 17-20 21-24 > 24 Unknown Total GeorgiaState No.201 28.8 % No.326 46.2 % No. 74 10.5 % No. 83 11.8 % No. 16 % No. 1 % No. 2 % No. % 'OregonMarylandHawaii]. 2 1,124 571$46 15.617.830.9 3,5891,3081,331 49.940.748.6 1,193 522309 16.616.311.3 1,158 760135 16.123.7 4.9 4941 3 1.52.3 11 -- 0.40.1 68 0 0.00.32.5 3,2102,741 705 100.0 TOTALSouth Carolina' 2,768 24 19.4 6.1 6,712 158 47,140.3 2,220 122 15.631.1 2,187 51 15.413.0 2551323 17 1.84.3 17 5 0.11.3 8515 0 0.80.03.8 14,244 7,196 392 100.0 2.1, IfarchJuly -11 December. - December 31, 1970, elective abortions only. *All4.3. states with data available. February> - December. 21 weeks. MMWMFOW

Most of the individual hospitals which provided data on indications for abortions performed in their facility reported a pattern similar to that shown in Table 10. The outstanding exception was Bernalillo County Medical Center in Albequerque, New Mexico where 63 percent of the abortions were performed to protect the woman's physical health.Prior to July 1, when legal abortions became available in New York, New Mexico women who anticipated rejection of their request for gbortion frequently stated their intent to seek an illegal abortion in Juarez, Mexico. at Bernalillo County Medical Center often agreed to perform a legal, hospital abortion to protect the woman from the risk of physical harm associated with an illegal abortion.

Table 11 shows weeks of gestation for gbortions performed in five states. The largest number were performed in the 9th through the 12th weeks of gestation. There was fairly wide variation among these states regarding this aspect of their abortion practices. Table 12 presents the cumulative distribution by length of gestation for abortions in the same five states. Two-thirds were performed before the end of the 12th week, and 97.5 percent by the end of the 20th week. Although nearly 91 percent of the abortions in Hawaii were performed by the end of the 16th week of pregnancy, only 77.5 percent were performed by the end of the 16th week in South Carolina. Two special studies of abortion in New York City, included in this report, implicate advanced gestation as an important factor contributing to morbidity and mortality associated with legal abortion.

Table 12

CUMULATIVE PERCENT DISTRIBUTION OF LEGAL INDUCED ABORTIONS BY MENSTRUAL WEEKS OF GESTATION SELECTED STATES* 1970

State < 8 9-12 13-16 17-20 > 21 Unk. Total

Georgia 28.8 75.0 85.5 97.3 99.7 0.3 100.0 Hawalil 30.9 79.5 90.8 95.7 97.6 2.5 100.0 Meryland2 17.8 58.5 74.8 98.5 100.0 100.0 Oregon 15.6 65.5 82.1 98.2 100.0 100.0 S.C. 6.1 46.4 77.5 90.5 96.1 3.8 100.0

TOTAL 19.4 66.5 82.1 97.5 99.4 0.6 100.0

1. Nerch 11 - December 31, elective abortions only. 2. July - December. 3. February - December.

*A11 states with data available.

41. 23 25 LEGAL ABORTIONS REPORTED BY TYPE OF PROCEDURE Table 13 Amniotic SELECTED STATES* 1970 State Sharp D&CNo. % Suction D&CNo. Z_ ReplacementNo. Fluid HysterotomyNo. HysterectomyNo. No. Other % UnknownNo. % Mo. Total 7 GeorgiqAlaskaHawaii' 1 2 360101378 92.630.831.7 664 95 2 56.829.8 0.5 118 39 1 12.210.10.2' 10 41 0.20.91.3 1720 4 6,31.01.5 22 01 0.00.35.4 59 18.5 00 0.00.0 1,169 408319 100.0100.0 NewUp-StpteMaryland4 York City4 4 17,239 6,172 363 39.211.333.3 18,427 6,1961,446 41.933.445.0 1,0727,5842,095 33.417.311.3 162709364 5.01.62.0 317146 00 0.00.04.5 21 90 0.10.00.70.0 3,708 20.0 0 0.0 0.0 43,959518,535 100.03,210 100.0100.0 TOTALOregonS. Carolina6 26,201 1,515 73 34.821.118.6 30,687 3,704 153 51.540.839.0 12,615 1,602 104 16.826.522.3 1,307 49 8 0.71.72.0 536 32 0.78.24.4 7421 0.15.4 3,768 1 0.35.00.0 75,188 7,196 392 100.0100.0 1. July 29 - December 31. 2.4.3. MarchOctoberJuly 13- -Decee,er.- December.July 15, 5.*All6. states with data available. FebruaryAbortions - reportedDecember. by certificates only. Table 13 shows the type of procedure used to perform abortions. More than 75 percent were performed by dilatation and curettage using either sharp or suction curets. Hysterotomy and hysterectomy accounted for only 2.4 percent of the cases. The relatively new suction dilatation and curettage method has been more widely accepted in some statesthan in others; Alaska is the only state which reports almost all D&C abortions performed with sharp curet. Predictably, those states in which a larger percent of abortions were performed later in gestation also show a large: percent performed by the replacement of amniotic fluid withhypertonic saline.

V. REPORTS OF SPECIAL STUDIES

; A. Interim Report on the Joint Program fOr. the Study of Abortion Gm Reported by Christopher Tietze-, M.D., Associate. Director, Bio- Medical Division, The Population CounC11,-and Sarah Lewit, Research Associate. This report is based on 42,598 abortion.case reports from 64 institutions participating in the Joint program for the Study of Abortion Four extramural abortion clinics participating. In the program accounted fm 17 percent of the cases. Approximately .71 percent of the abortions report by all participating institutions were performed within the first 12 week! of gestation. Twenty-six percent were performed at 13 to 20 weeks of gestation,- and three percent after the 20th week. The proportion of secol trimester abortions was highest for the youngest women and lowest for worm in their early thirties. Nearly 70 percent were performed by the suction method; 63 percent of these were performed as an out-patient procedure.

Complication rates were calculated excluding women with pre- existing complications and/or concurrent tubal sterilization. Of the remaining women, 9.3 percent experienced one or more complications; however, this includes all reported complaints, many of which were comparatively trivial. Slightly more than one percent of the patients experienced a complication considered to be rnajor." This number includes 90 cases of perforated and one death. Three additional deaths are known to have occurred among the 2,753 women excluded from the analysis o: complications because of pre-existing medical conditions and/or concurren: tubal sterilization. The overall complication rates (based on all complications) were higher for abortions performed at 6 weeks or less thal for abortions performed at7 or 8 weeks, after which the complicatiOn rate increased to a maximum at 15-16 weeks, followed by a decline. Bot1t the rates Tor all complications and the rates for najor complications were three or more times higher for abortions performed at 13 or more weeks of gestation as compared with abortions performed before the end of the 12th week. Complication rates were highest for women over 40 years of age. In each age group, high-parity women had the highest complication rates. Complication rates were lowest for abortions perform' by suction, followed in ascending order, by sharp curettage, amniotic fluid replacement, hysterotomy and hysterectomy.

25 27 B. New York City

1. The Practice of Legal Abortion, July 1 - December 31, 1970. Reported by Jean Pakter, M.D., Frieda Nelson, and Martin Svigir, New York City Health Department, James B. Kahn, M.D., Family Planning Evaluation Activity, CDC.

The New York City Health Department reported a total of 68,995 legal abortions between July 1 and December 31, 1970, the first 6 months the new New York State law was in effect. Approximately half of these were performed on women who were not residents of New York State.New York City's abortion ratio of 894 abortions per 1,000 live births during that 6-month period is the highest reported for any jurisdiction in the United States.

Analysis of New York City abortions by type of facility they were performed in shows differences between services received by private patients and those provided for indigent women. The abortion ratio reported by private hospitals (2,649 abortions per 1,000 live births) was more than twice as great as the ratio of 1,015 reported by New York City municipal hospitals. A similar trend was seen in the voluntary hospitals, which serve both private and public patients. Abortion ratios reported by private services in the voluntary hospitals were 1.74 tines as high as those reported by the publicly financed tward" services.

A higher percent of private patients obtained their abortions before the end of 12 weeks gestation and by the D&C method than did ward patients: Only 65 percent of mmnicipal hospital patients and 67 percent of ward service patients in voluntary hospitals had their abortions done before the end of the 12th week. In contrast, 79 percent of the abortions performed in private hospitals and nearly 96 percent of those in non- hospital abortion clinics were performed during or before the 12th week. Virtually the entire caseload of non-hospital abortion clinics is private patients, many from out of state. Slightly more than 66 percent of the abortions performed in municipal hospitals were done by dilatation and curettage, as compared with 84 percent of the abortionsperformed in private hospitals and virtually all of the abortions performed in non- hospital clinics.

2. Abortion Mortality, 1970. Reported by Jean Pakter, M.D., and Frieda Nelson, New York City Health Department; S. Beach Conger, M.D., Family Planning Evaluation Activity, CDC. Analysis of maternal mortality in New York City for 1970 showed a total of 25 reported deaths due to induced abortion, 11 of which were illegal abortion associated deaths reported before July 1. During the second half of the year, after the new abortion law was instituted, a total of 14 abortion deaths were reported, of which six were associatedwith illegal abortions,and eight with legal abortions performed by a physician.

26 Five of these eight deaths occurred within the first four weeks the new law was in effect. The epidemic curve for induced abortion deaths in New York City (Figure 6) shows that although there was substitution of legal for illegal abortion deaths, no significant decrease in total abortion mortality occurred following institution of the new law; however, the period elapsed is probably too short to predict the long term effects of the new law on abortion mortality. Only one death was reported during .the last 10 weeks of the year.

Fig6INDUCED ABORTION DEATHS, NEW YORK CITY

8 - ElLEGAL ABORTION 6 DiILLEGAL ABORTION cn aDEATH OCCURRING OUTSIDE N YCrTY a Lii 2-

0 lig itiMEEMENIIIIIMEN MEM wE;K: Na 24 6 8 1012 14 16 18 202224 26 28 30 32 34 36 38 4042 444648 50 se MONTH J F M A ha J J A S 0 N 0 1970

Of the eight deaths associated with legal New York City abortions in 1970, three followed abortions performed by hysterotomy, one followed replacement of amniotic fluid with hypertonic saline, and four followed a D&C procedure. Three of the women who died had significant underlying medcal conditions that contributed to their deaths. Three of the four deaths associated with dilatation and curettage resulted from perforation of the uterus; two involved a sharp D&C procedure perforbed on women with pregnancies advanced beyond 12 menstrual weeks.

Six of the eight legal abortion deaths were associated with abortions performed in a hospital and two were associated with abortions performed in private physicians' offices. No deaths were reported following abortions performed in out-patient abortion clinics. These facilities restrict services to women in the first 12 weeks of pregnancy who have no complicating medical problems.

tilthough an estimated 72 percent of the women who received abortions in New York City during the 6-month period were white, six of the eight legal abortion deaths and all of the illegal abortion deaths were among blacks and Pue Ricans. Estimated race-specific legal abortion mortality rates (Table 14) showE

27 Table 14

ESTIMATED* LEGAL ABORTION CASE FATALITY RATE BY RACE NEW YORK CITY July - December '1970 '=-

Estimated* Abortion Deaths/ Race Abortions Deaths 100,000 Abortions

White 49,956 2 4.0 Black 16,003 4 25.0 Puerto Rican 3,036 2 65.9

TOTAL 68,995 8 11.6

*The proportion of certificates filed for each race from each type of abortion facility was mmltiplied by the total number of abortions reported from each type of facility to estimate the number of abortions performed on each race by type of facility. For each race,.the estimates for each type of facility were summed.

Table 15

MATERNAL MORTALITY ASSOCIATED WITH AND MORTALITY ASSOCIATED WITH LEGAL ABORTION BY RACE NEWYORK CITY

Maternal Deaths/100,000 Deaths/100,000 Legal Race Live Births, 1969-1970 Abortions, July-Dec. 1970

White 13.0. 4.0 Black 63.0 25.0 Puerto Rican 26.7 65.9

TOTAL 29.4 11.6

28 dramatic differences in race-specific mortality. Comparison of the case fatality rates for live births and for legal abortions by race (Table 15) shows that although blacks and Puerto Ricans have a higher mortality than whites in both categories, only in Puerto Ricans is the case fatality rate from legal abortions higher than the case fatality rate from live births.

Table 16 shows estimated New York City abortions and reported abortion deaths by weeks of gestation at time of abortion for July 1, 1970 - January 31, 1971. The mortality rate for abortions performed after the 12th week of gestation was three times as great as the rate for abortions performed at 12 weeks or less.

The total case fatality rate for legal abortions in New York City was 11.6 per 100,000 abortions during the first 6 months under the new law. Again, this time period is probably too short to accurately reflect practices in New York City.*Legal abortion mortality rates in other countries range from a high of 41.4 in Denmark to a low of 1.2 in Hungary.

*The legal abortion mortality rate in New York City for the first 11 months (July 1, 1970 - May 31, 1971) was 6.0 per 100,000 abortions.

Table 16

LEGAL ABORTION CASE FATALITY RATE BY LENGTH OF GESTATION NEW YORK CITY July 1, 1970 - January 31,1971

Length of Estimated* Gestation Number of Abortion Deaths/ (Weeks) Abortions Deaths 100,000 Abortions

12 or less 59,024 4 6.8 More than 12 23,542 5 21.2

TOTAL 82,566 9 10.9 *For each category of gestation the proportion of certificates filed for that category for July - December 1970 was multiplied by the number of abortions reported for July 1970 - January 1971.

29 3. Investigation of a Cluster of Uterine Perforations. Reported by Jean Pakter, M.D., Director, Bureau of Maternity Services and Family Planning, New York City Health Departnt; Dennis Nicholas, M.D., Marion County Coroner, Indianapolis, Indiana; S. Beach Conge M.D., Family Planning Evaluation ActivitY., CDC.

The death of a mid-western woman following an abortion in New York City led to the discovery of a cluster of six cases of uterine perforation related to a single physician using suction curettage. Five of these wome- required an exploratory laparotomy and three had a hysterectomy. The physician was a board eligible obstetrician-gynecologist who had performed 1,668 abortions in his office and in two outpatient abortion clinics betwe4 July 1, 1970 and January 13, 1971. In the first 1,379 cases he usedthe si diameter Rarman cannula, and in thelast 289 he used the Sorensen cannula. In cases of advanced gestationeither ovum forceps or sharp curet wasused to complete the abortion. All cases were done either underlocal anesthes- or without . Four perforations occurred in 1,379 abortions performed with the Rarman cannula and two perforations in 289 abortions performed with the Sorensen cannula, resulting in perforation rates of 2.9 and 6.9 per 1,000 abortions for these two methods respectively. One of the women had an unrecognized congenital uterine abnormality, but none of the other cases involved pre-disposing medical conditions. By the physician's criteria, all six women were between 10 and 12 menstrual weeks of gestation at time 4 abortion, although when their length of gestation was calculated from date of last menstrual period, four were found to be beyond 12 weeks. Length o: gestation is known for 809 of the abortions performed in this physician's office. Extrapolating data on length of gestation for those cases to the total number of abortions he performed makes it possible to calculate a perforation rate by length of gestation (Table 17).The perforation rate is zero for cases 10 weeks or less but increases to 96.8 for cases 15 week ! or greater. The overall perforation rate for abortions he performed at 12 or fewer weeks gestation was 1.3 per 1,000 abortions, while for pregnanciez of greater than 12 weeks the perforation rate was 42.1. The total perforation rate for this physician was 3.6 per 1,000 abortions.

A physician might perform an aspiration abortion on a patient beya 12 weeks of gestation either because he believes the patient is a good ris- in spite of advanced gestation, or because he has misjudged the length of gestation. Comparison of this physician's estimated length of gestation a: the calculated menstrual weeks of gestatian shows the calculated length of gestation to be higher in 5 of 6 cases. la two cases the length of pregna- was verified by pathological examination and was found to correspond to the length of gestation calculated from last menstrual period, suggesting that the physician was underestimating the length of pregnancy.

30 The difficulty of accurately diagnosing length of pregnancy during the 10 to 12 week period indicates that clinical decision making is particularly critical at this point. This epidemic suggests that restricting abortion by the DIX method to women whose length of gestation is less than 13 weeks as calculated by date of last menstrual period would considerably reduce the risk of perforation.

Table 17

ADJUSTED UTERINE PERFORATION RATE BY LENGTH OF GESTATION FOR ABORTIONS PERFORMED BY A SINGLE PHYSICIAN NEWYORK CITY July 1, 1970 - January 13, 1971

Length of Gestation Rate/1,000 (Menstrual Weeks) Abortions* Perforations Abortions

8 or less 468 0 - 9-10 585 0 - 11-12 520 2 3.8 13-14 64 1 15.6 15 or more 31 3 96.8

TOTAL 1,668 6 3.6

*Based on data for 809 abortions for which length of gestation was reported.

C. Decrease in Septic Abortion Morbidity in a Municipal Hospital, Los Angeles, California. Reported by Charles Ballard, M.D., -Gall V. Anderson, M.D., Chief, Division of Gynecology and Edward J. Quilligan, M.D., Department of Obstetrics and Gynecology, LAC/USC Medical Center.

A law to increase availability of legal abortions was passed by the California Legislature in 1967. The Los Angeles County/University of Southern California Medical Center (LAC/USC) has collected data on the number of women admitted to the hospital for care related to non-hospital induced septic abortions as well as the number of legal abortions performed at LAC/USC Medical Center for every year Irom 1966 through 1970(Table 18). Admissions to the hospital for treatment of septic, non-hospital induced abortions declined from an average of 662 per year for the period 1966-1968 to 559 in 1969, and 305 in 1970. The septic abortion ratio during this 5-year time span fell from 72 septic abortion admissions per 1,000 live births in 1966 to 31 septic abortion admissions per 1,000 live births in 1970.

This decline in septic abortion admissions appears directly relatedto the increase in hospital-performed abortions from 2 in 1966to 3,469 in 1970.

Table 18_

ABORTION PATIENTS AT LOS ANGELES COUNTY/ UNIVERSITY OF SOUTHERN CALIFORNIA MEDICAL CENTER, 1966-1970

Admissions for Abolt:ons Induced Non-Hospital Induced at L.*SC Year Septic Abortions Medic.1 Center

1966 646 2 1967 638 7 1968 701 127 1969 559 585 1970 305 3,469

D. Hospital Study of Abortion Services (HSAS), OctOber-December, 1970.

In late 1970, four hospitals in different geographic areas of the country initiated the Hospital Study of Abortion Services (HSAS) with CDC serving as study coordinator. This study is intended to characterize the women who receive abortion services and to evaluate morbidity and mortality associated with legal and illegal abortions, and the inter-relationship between illegal and legal abortion morbidity and mortality.

Each hospital is situated in a large metropolitan area. Three of the hospitals serve primarily indigent patients; the fourth serves primarily private patients. A report is completed for each woman who has either had an abortion induced in the hospital or has been admitted for complications of a non-hospital abortion.

During this 3-month period a total of 1,815 abortions were performed in the four hospitals, resulting in a ratio of 341 abortions per 1,000 live births (Table 19). The abortion law of the state in which Hospital B is located is at least as permissive as the law under which abortions are performed in hospitals C and D, although there is greater than a 10-fold difference in their abortion ratios.

32 34 Table 19

HOSPITAL INDUCED ABORTION RATIOS HOSPITAL STUDY OF ABORTION SERVICES October - December 1970

Abortions/ Hospital Abortions Live Births 1,000 Live Births

A 479 644 744 56 1,620 35 956 2,414 396 324 641 505

TOTAL 1,815 5,319 341

Changing abortion practices overa period of time are shown for Hospital D in Figure 7. 'Monthly figuresfor abortions induced at the hospital from July 1965 through December1970 show a sharp increase beginning in January 1967 and continuing until thefirst part of 1970. In 1970, the rate reached a relatively constant levelof 120 to 150 abortions per month.

The majority of abortions at each of these hospitals were performed by suction dilatation and curettage (Table 20). Sharp D&C was used as a primary abortion procedure in only six cases. The high percent of abortions performed by amniotic fluid exdhange reflects the large number of women whose abortions were performed after the 15th week of pregnancy in hospitals A and C. Women who were never married accounted for 54 percent of those who received abortions in these four hospitals during a 3-month period; 49 percent of the women had no living children.

35- 33 HOSPITAL INDUCED ABORTIONS, HOSPITAL Figure 7 D, JULY 1965 DECEMBER 1970 150160 130140 120110 100 90 LAW REVISED EFFECTIVE NOVEMBER, 1967 4Lii 8 070 ok) 5060 340 0 20 10 J A SON DJ FM AM J J A SON D 1965 ill!!! I 1966 JFMAMJJASOND 1967 JFMAMJJA SONO 1968 JF MAMJJ ASOND 1069 JFMAMJ JA SONO 1970 wiat Table 20 HOSPITAL ABORTIONS BYHospital TYPE OF StudyPROCEDURE of Abortion Services October-December 1970 No. Suction D&C % Sharp D&C % No.ExchangeAmn. Fl. % Hysterotomy No. Hysterectomy No. Other Unknown Total aj Hospital A 274 36 64.357.2 No. 0 0.0 197 17 30.441.1 03 %0.00.6 30 0.05.4 % No. 05 0.01.0 No. 0 0.0 No.479 56 100.0100.0 TOTAL DC 1058 244504 58.375.352.7 60 0.31.90.0 669402 53 36.916.442.1 063 0.30.0 4740 4 /.4.2 2.62 2414 5 4.31.30.5 532 0.90.20.3 1815 956324 100.0100.0100.0 IV. LEGAL NOTES

A. History of Abortion Law in the United States Prior to 1967.

Although early in the United States did not treat abortion before "" as a criminal offense, later, mainly during the 19th Century, each of the states passed laws to restrict the practice of abortion. Most of these laws stated that abortion was permitted only when necessary to preserve a pregnant woman's life. The only exceptions to that generalization were the abortion statutes of New Jersey, Massachusetts, and Pennsylvania, which were worded vaguely to prohibit "unlawful" or "illegal" abortions, and those of Alabama and the District of Columbia which provided for legal abortion to preserve both the life and the health of a woman endangered by carrying her pregnancy to term. In effect all of these laws were similar, prohibiting abortion except in situations of rather severe physical disease or impairment. This legal status existed unchallenged, if sometimes violated, until 1966, when Mississippi altered its law slightly to also provide for legal abortion of pregnancies resulting from rape.

B. The American Law Institute Model Penal Code on Abortion.

In 1957,the American Law Institute (ALI), composed of eminent lawyers, law professors,andjudges from throughout the country, roposed a model penal code on abortion. Incorporated in this code was the concept that abortions should not be considered a crime when performed by a licensed physician on grounds of substantial risk that continuance of the pregnancy would gravely impair the physical or mental health of the woman, or that the child resulting fram the pregnancy would be born with grave physical or mental defect, or in cases of pregnancy resulting from rape orincest.4 A few years after this action by the ALI an epidemic of rubella (German Measles) which resulted in the birth of an estimatPd 20,000 defective babies in the U.S.3 heightened public acceptance of the concept that legal abortion is-necessary in some situations. During this epidemic nany physicians ignored state abortion laws to perform abortions on women exposed to rubella in the first 3 months of pregnancy, and the medical profession in many states was supportive of changing the laws to correspond with this practice.

In April 1967 Colorado became the first state to enact a new abortion law designed along the lines proposed by the American Law Institute. By the end of 1967, North Carolina and California had also passed abortion legislation based on the ALI guidelines. Georgia and Maryland enacted similar laws in 1968, followed by Arkansas, Delaware, New Mexico, and Oregon in 1969, to bring the total number of states with new laws to nine by January 1, 1970. The Oregon law of August 1969, differed from the others by indicating that physicians should take account of thewoman's total environment "actual or reasonably foreseeable" when determining if there is risk that continuation of the pregnancy would impair her physical or mental health.

36 38 C. Judicial Decisions Affecting American Abortion Laws Prior to 1970.

In September 1969, the Supreme Court of California rendered a decision in the case of People v. Belous4, which at the same time invalidated the pre-1967 abortion law of California and raised the issue of constitutionality of state aboltion statutes.. The court declared the California law to %e unconstitutional on grounds that (1).the law was vague and therefore violated the due process provisions of the 14th amendment of the.Constitution; (2) under the right to privacy, it violated a woman's fundamental right.to choose whether or not to have children, 'ami.(3) that, due to advanced in medicine, the state no longer had a compelling'interest in.preventing abortions as a means of protecting women's health. This court action was, however, directed at an old California abortion law and did not have a legal effect on the 1967 California Therapeutic Abortion .Act, which had been passed by the legislature during the.time'this case.was in the courts. - Also in 1969, the U.S. District'Court for the District of-Columbia, deciding on the case of Dr. Milan Vuitch, a Washington physician indicted for illegal abortion, held the District of Columbia's 1901'statute which made abortion a felony unless performed for preservation of the pregnant woman's life or health to be unconstitutional. Vagueness.and the right to privacy were stated as the basis for this decision.5

D. Abortion Law' Changes in 1970.

During 1970, three more states put into effect abortion laws similar to the American Law Institute Model Penal Code.-An ALI-type law 'became effective in South Carolina on January 27 and in.Virginia on June 27. A similar law had passed the Kansas legislature in 1969, but did not become effective in Kansas until Julyj, 1970. More significant, however, were four'other states which, in-1970,, enacted an.entirely new kind of abortion law which contained no restriction on the reasonS for which an abortion may be legally obtained.. Hawaii was the first state to.pass this kind of law. The Hawaiian law, effective on March 10, 1970, requires only that abortions (1) be performed by a licensed medical or osteopathic physician or surgeon, (2) be performed in a hospital licensed by the _Department of Health or operated by the Federal Government or an agency thereof,.(3) be performed only on women who have been residents of the.state for at least 90 days preceding the abortion, and (4) be performed prior to viability of the .6

The Alaskan law became effective on July 29, 1970, and requires that abortions (1) be performed only by a licensed physician, (2) in a hospital or other facility approved for that purpose by the Department of Health and Welfare or a hospital operated by the Federal Government or an agency of the Federal Government, (3) consent for abortion be Obtained from the parent or guardian of an unmarried woman less than 18 years of age, (4) abortions be performed only on women who have been residents of the state for at least 30 days prior to the abortion, and (5) abortions only be performed prior to viability of the fetus.7

37 a9 The New York law, which went into effect on July 1, 1970, contained fewer restriction:4 than those enacted in Hawaii and Alaska.The New York abortion law of 1970 requires only that all abortions (1) be performed with the consent of the women upon whom they are performed, (2) within 24 weeks from the commencement of pregnancy (unless, in the judgment of a licensed physician, abortion is necest§ry to preserve the women's life) and (3) only by a duly licensed physician.°

In Washington State the new abortion law resulted not from legislative action but as a result"of a successful public referendum held during the November 1970 general elections in the state.The result of passage of this referendum was to enact new abortion law in the state permitting termination of pregnancies when performed (1) by or under the supervision of.a licensed physician, (2) within 16 weeks after conception(and before quickening), (3) orqy on women who have resided in the state for at least 90 days prior to the abortion, and (4) witb the consent of thewoman's husband,if she is living with him, or if unmarried and under 18 yearsof age, with her consent and that of her legalguardian. This law went into effect in Washington on December 3, 1970.9

Significant court decisions rendered ip 197( incivIe three U.S. District Court decisions which found part cm all of a state's abortionlaw to be unconstitutional (asconsinn,Texas'1, and Ceorgial2). All of these cases are being appealed. A number of other cases have been heard in loer courts in states throughout the country.

Table 21 lists each state in one of eight categories on the basisof major legal requirements for performance of abortion inthat state, as of the end of 1970.

38 4 0 Table 21 MAJOR CATEGORIES OF AMEFOCAN ABORTION LAWS UNITED STATES JANUARY 1. 1971

...... MAJOR CATEGORIES OF SIATE ABORTION LAWS STATES HAVING SIMILAR ABORTION LAWS

I.Abortion elowed only when necessary to preserve the life of the Arizona, Connecticut, Florida. Idaho, Illinois. Indiana. pregnant woman: Iowa'', Kentucky, Louisiana2. Maine, Michigan. Minne- ..sota. Missouri. Montana. Nebraska. Nevada. New Hamp- shire. North Dakota, Ohio, Oklahoma, Rhode Island. South Dakota. Tennessee. Utah. Vermont, West Virginia. Wyoming.

II.Indications for legal abortion include threats to the pregnant woman's Mississippi. life and forcible rape:

: III."Unlawful" or "unjustifiable" abortions are prohibited: Massachusetts, New Jersey. Pennsylvania.

IV.Abortions allowed when convinuation of the pregnancy threatens the Alabama. woman's life or heetn:

V.American Law Institute Model Abortion Law: "A licensed physician - Arkansas. California (does not include fetal deformity), is justified in terminating a pregnancy if he believes that there is sub- Colorado. Delaware, Kansas. Maryland (does not include stantial risk that continuance of the pregnancy would gravely impair incest). New Mexico. North Carolina. South Carolina. the physical or mental health of the mother or that the child would Virginia. be born with grave physical or mental detect, or that the pregnancy resulted from rape, incest or other felonious intercourse":

VI.Abortion law based on the May 1968 recommendations of the Ameri- Oregon. can College of Obstetricians and Gynecologists. Allows abortion when .

the pregnancy resulted from felonious intercourse, and when there is . risk that continuance of the pregnancY wch.ild impair the physical or mental health of the mother. "In determining whether or not there is substantial risk (to the woman's physical or mental health), account may be taken of the mother's total environment, actual or reasonably

foreseeable": .

VII.No legal restriction on reasons for which an abortion may be obtained Alaska, Hawaii, New York, Washington. pnor to viability of the fetus:

VIII,Legal restrictions ::..n reasons for which an abort;on may be obtained District of Columbia. Georgia. Texas, Wisconsin3. were invalidatPd by court decision:

1.In State vs Dunklebarger, the Iowa statute which is couched in terms of saving the life of the woman, has been interpreted to suggest that Preservation of health is sufficient. 221 N.W. 592 (Iowa. 1928). . _ 2. Although the Louisiana abortion statute does not contain at, express exception to the "crime of abortion" the Louisiana Medical Practice Act authorizes the Medical Board to suspend or institute court proceedings to revoke a doctor's certificate to practice medicine in the state when the doctor has procured or aided or abetted in the procuring of an abortion "unless done for the of a woman whose lifeappears imperiled after due.consultation with another licensed physician." La. Rev. Stat. Ann. 37:1261. 3. The abortion law of several other states have been ruled unconstitutional by lower state trial courts: however, these decisicins are binding only in the jurisdiction in which the decision was rendered.

39 V. INTERNATIONAL NOTES

A. Canada

On August 26, 190, new abortionlegislation went into effect in Canada. Under the1969 law (Section 237 of theCriminal Code), abortion is illegal,unless performed underthe following circumstances:

1. The abortion must be performed bya medical practitioner licensed to practice medicine inthe province where the hospital in which the abortion is to beperformed is situated. The doctor may not be a member of a therapeutic abortioncommittee of any hospital anywhere.

2, The abortion must be performed inan accredited or approved hospital. :, An accredited hospital isone accredited by the Canadian Council on Hospital Accreditation.Approved hospitalsare those approved by the Provincial Ministerof Health for thepurposes of therapeutic abortions:

3. The abortion must have beensanctioned by the Therapeutic Abortion Committee of the hospitalin which the abortion isto be performed. This committee is composed ofat least three physicians licenseJ in the province where thehospital is situated.

4. The basic criteria for theperformance of a legal abortion is that,, in the opinion of the TherapeuticAbortion Committee, the continuation of the pregnancy would belikely to endanger the life or healtn of the pregnant woman.

During 1970 a total of 11,200 legalabortions were performed in Canada and were reported to .the Dominion Bureau of Statistics inOttawa. The 1970 abortion ratio for Canadawas 30 per 1,000 live births.

B. Finland

A new abortion law went into effect inFinland on June 1, 1970. According to the new law, abortionmay be induced at the woman's request if:

1. Continuation of the pregnancyor delivery of a child would endanger her life or health on the groundsof her disease, physical deformity, or weakness,

2. Delivery and care of the child wouldplace a noteable strain on her in relation to her living conditions andthose of her family and other circlimstances,

40 42 3. She became pregnant in conditions referred to in some chapters in the criminal law, or if the act invo?ved violation of the woman's freedom of action,

4. She ::as not 17 years of age when she became pregnant or was 40 years old cr over or had already given birth to four children,

5. There is reason to assume that the child would be mentally retarded or would have or would develop a severe disease or physical defect, or

6. A disease of either parent or both parents, mental disturbance, or other comparable cause limits seriously their ability to care for the child.

Between June 1, the date the new law became effective, and December 31, 1970, 10,380 legal abortions were performed and reported in Finland. For the entire year of 1970, 14,525 abortions were reported in the country, for a ratio of 225:3 abortions per 1,000 births.13

C. Update on International Abortion Ratios

Table 22 depicts recent abortion ratios in four foreign countries. Three of these countries have exl:erienced some increase in the proportion of abortions to live births since their previous reporting period. In Czechoslovakia, the abortion ratio has increased from 344 in 1965, to 461 in 1969. England and Wales have experienced a more acute increase, from a ratio of 46 abortions per 1,000 live births in 1968, the first year the new abortion act was in effect, to a ratio of 107 abortions per 1,000 live births in 1969. The ratio for Japan increased slightly, from 387 in 1967 to 405 in 1968. Hungary is the only country among these four which reported a smaller abortion ratio in 1969 than during its most recent previous reporting period--1,356 abortions per 1,000 live births reported in Hungary for 1965, as compared to 1,341 abortions per 1,000 live births reported in 1969.

Table 22

INTERNATIONAL ABORTION RATIOS SELECTED COUNTRIES

Reporting Abortions/1,000 Country Period Abortions Live Births Live Births

Czechoslovakia]. 1969 102,800 222,803 461 2 England & Wales 1970 83,851 784,000 107 Hungary1 1969 206,817 154,176 1,341 Japan1 1968 757,389 1,870,159 405

1. Source of data: C. Tietze, M.D., The Population Council. 2. Source of data: The Registrar General's Quarterly Returns, Nos. 485-488, 1st - 4th quarters, 1970. Live births are estimated.

41 43 We wish to acknowledge the following organizations and individuals whose contributions made this report possible.

Cecil Baldwin, Chief Public Health Section Dominion Bureau of Statistics Ottawa, Canada

Clayton T. Beecham, M.D., Director Gynecology-Obstetrics The Geisinger Medical Center Danville, Pennsylvania

Thomas A. Burch, M.D., M.P.H. Chief, Research and Statistics Office Hawaii State Department of Health

Bureau of Maternal and Child Health California Department of Public Health

David Charles, M.D., Chairman Department of Obstetrics and Gynecology University Hospital Boston, Massachusetts

Irvin M. Cushner, M.D., Director Center for Social Studies in Human Reproduction Johns Hopkins University School of Medicine

Donald J. Davids, Chief Records and Statistics Section Colorado State Department of Public Health

John P. Emich, Jr., M.D. Administrative Chairman Department of Obstetrics and Gynecology Philadelphia General Hospital

Charles E. Flowers, Jr., M.D.,.Chairman Department of Obstetrics and Gynecology The Medical Center University cf Alabama in Birmingham

Donald K. Freedman, M.D., Director Division of Public Health Alaska Department of Health and Welfare

Malcolm G. Freeman, M.D., Chief Division of Perinatal Pathology Grady Memorial Hospital Emanuel A. Friedman, M.D. Obstetrician-Gynecologist-In-Chief Beth Israel Hospital Boston, Massachusetts

Roberto Fuentss, Chief Statistics and Research Office District of Columbia Department of Human Resources

Walter P. Gust, Director Bureau of Family Planning Commonwealth of Virginia Department of Health

S. Leon Israel, M.D., Chief Obstetrics and Gynecology Pennsylvania Hospital Philadelphia, Pennsylvania

Leroy A. JaCkson, Jr., M.D. Maternal Health Division District of ColuMbia Department of Human Resources

Selig H. Katz, M.D., Director Bureau of Maternal and Child Health and Family Planning State of New York Department of Health

Kermit Krantz, M.D., Chairman Department of Obstetrics and Gynecology Mt. Sinai Hospital Milwaukee, Wisconsin

Sarah Lewit Research Associate The Population Council

W. Joseph Nay, M.D., Chairman Committee on Maternal Health Madical Society of the State of North Carolina

Catherine B. Middleton, Director Maternal and Mild Haalth Delaware State Board of Health

.Rpbert A. Nunaidk, Ph.D.,,Chairman Department of_Obstetrics and Gynecology University of New Mexico SChool of Medicine

Oregon State Board of Health

43

J.E. Padgett, Jr:, M.D., Chief Bureau of Maternal and Child Care South Carolina Board of Health

Jean Pakter, M.D., Director Bureau of Maternity Services and Family Planning City of New York Department of Health

Phyllis Parker, R.R.L. Chief Medical Record Librarian Madison General Hospital Madison, Wiscons5n

Ben M. Peckham, M.D., Chairman Department of Gynecology and Obstetrics The University of Wisconsin Medical School

Eugene C. Sandberg, M.D., Associate Professor Department of Obstetrics and Gynecology Stanford University Medical Center

Patricia Schloesser, M.D., Director Maternal and Child Health Kansas State Department of Health

Albert K. Schoenbucher, M.D., Director Maternal Health Service Georgia Department of Public Health

J. King B.E. Seegar, M.D., Chief Maternal and Family Planning Section Division of Maternal and Child Health Maryland State Department of Health

William G. Slate, M.B., Ch.B., M.S., Chairman Division of Obstetrics and Gynecology Albert Einstein Medical Center Philadelphia, Pennsylvania

Roy Smith, M.D., Associate Professor School of Public Health University of Hawaii

Donald P. Swartz, M.D., Director -Department of Obstetrics and Gynecology Harlem Hospital Center

41; Melvin L. Taymor, M.D. Chief of Gynecology Peter Bent Brigham Hospital Boston, Massachusetts

Christopher Tietze, M.D., Associate Director Bio-Medical Division The Population Council

De_partment of Obstetrics and Gynecology University of Southern California

Vital Statistics Section Division of Health Washington State Department of Social and Health Services

John Yeransian, Chief Obstetrics and Gynecology Newton-Wellesley Hospital Boston, Massachusetts REFERENCES

1. Potts DM: Postconceptive Control of Fertility. International Journal of and Obstetrics, VIII, November 1970.

2. American Law Institute, Model Penal Code (proposed offiCial draft), Sect. 230.3 (2), May 4, 1962.

3. National Communicable Disease Center: Rubella Surveillance Report, No. 1, June 1969.

4. 80 Cal. Rptr. 354 (1969).

5. 305 F. Supp. 1032 (1969).

6. Hawaii Public Act No. 1, Ch. 768, Laws 1970.

7. Alaska 11.15.060.

8. New York Penal Code. 125.05.

9. Washington 9.02.

10. Wisconsin Babbitz v. McCann. 310 F. Supp. .293 (E.D. Wisc. 1970).

11. Texas Roe.v. Wade. 314 F. Supp. 1217 (N.D. Tex. 1970).

12. Georgia Doe v. Bolton. 319 F. Supp. 1048 (N.D. Ga. 1970).

13. Turpeinen, Kaisa. Legal . International Federation Medical BulletIn, V, June 1971.

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